_ During the course of the inquest evidence was given that controlled checks processes had been such that it was not easily identified that drugs were not accounted for e.g: Stock sheets were inaccurate. The home in question had tightened up its processes since the incident: However the inquest heard that this issue may well arise in the future in other carelnursing home settings as there is no clear process for handlinglrecording the use of controlled drugs: ACTION SHOULD BE TAKEN In my opinion, action should be taken t0 prevent future deaths and believe you have the power to take such action YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st April 2020. 1, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely husband of the deceased; 2) Manchester City Council, who may Tind it useiulor of interest: am also under a to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations t0 me; the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner: Alison Mutch OBE HM Senior Coroner 25.02.2020 drug duty